Comparison of tuberculosis incidence in ankylosing spondylitis and rheumatoid arthritis during tumor necrosis factor inhibitor treatment in an intermediate burden area

Abstract

Clinical characteristics of antitumor necrosis factor (TNF) agents-related tuberculosis (TB) in ankylosing spondylitis (AS) are not well described. The aim was to compare the incidences and the characteristics of TB in AS and rheumatoid arthritis (RA) during TNF inhibitor treatment. AS (n = 1,322) and RA (n = 3,154) patients who received medical care between January 2001 and August 2011 were enrolled. The incidence of TB in patients treated, or not, with TNF inhibitors and the clinical features associated with TB were explored. Seven patients with AS and seven with RA developed TB while receiving TNF inhibitor therapy, resulting in an incidence rate of 600.2/100,000 person-years (PYs) (95 % confidence interval (CI), 241.3-1236.3) for those with AS and 771.6/100,000 PYs (95 % CI, 310.2-1589.9) for those with RA. Incidence rate ratios for TNF inhibitor-treated vs. untreated patients were 4.87 for AS (95 % CI, 1.50-15.39; p < 0.001) and 3.61 for RA (95 % CI, 1.38-8.07; p < 0.001). Low body mass index was identified as a significant risk factor for TB in the AS group (odds ratio (OR), 13.0; p = 0.002). Extrapulmonary TB was predominant at 85.7 % during TNF inhibitor treatment. Three (42.8 %) of the AS patients, but none of the RA patients, developed TB with concomitant isoniazid. All AS patients recovered from TB whereas two of seven RA patients died. Treatment with TNF inhibitors significantly increases the risk of extrapulmonary TB in AS. Symptoms of infection should warrant clinicians to evaluate for TB during TNF inhibitor therapy in AS patients.

Mycobacterial diseases developed during anti-tumour necrosis factor-α therapy

“…There were no cavitary lesions or consolidation noted in half of the TB patients. Extrapulmonary manifestation was higher in patients receiving anti-TNF-a therapy than in the general population, which has also been shown in previous studies [6,9,10]. These findings may be explained by systemic spreading of mycobacteria due to inhibition of TNF-a by anti-TNF-a therapy in TB patients [28,29].…”

“…Clinical data on TB in patients treated with TNF-a antagonists have been extensively reported in several studies [4,6,7,9,10]. In addition, as clinicians are concerned about the development of TB in patients treated with TNF-a inhibitors, there is a focus on screening and treating latent TB infection (LTBI) before administering TNF-a inhibitors.…”

“…Reactivation of tuberculosis (TB) is the most frequently encountered infectious complication during TNF-a antagonist therapy [5][6][7]. Development of TB in patients treated with TNF-a inhibitors has already been reported in South Korea [8][9][10].…”

Factors Affecting the Tuberculosis Risk in Patients Receiving Anti-Tumor Necrosis Factor-α Treatment

“…Also agents used for the treatment of rheumatoid arthritis may further increase the risk of TB [34,35,36]. Recently, Kim et al [37] reported that the TB incidence in ankylosing spondylitis and rheumatoid arthritis patients receiving aTNF-α-T is similar, and EP-TB was prevalent in both conditions. On the other hand, a higher risk of TB was observed in patients diagnosed with Behçet's disease in our study (p = 0.003), consistent with some previous reports suggesting an association between an elevated TB risk and Behçet's disease [38,39].…”

Overview of biologic treatments in the elderly

“…For instance, compared with subjects naive to anti-TNF therapy, the incidence of tuberculosis is multiplied by a factor of four in RA and in AS, and this irrespective of the anti-TNF drug. Age > 60 years in RA (OR 15.9, 95% CI: 1.8-147.6), and BMI < 22 kg/m 2 in AS (OR 13, 95% CI: 1.51-111.92) were significant risk factors for this complication [39]. There appear to be large differences between the different anti-TNF drugs.…”